Amjad AlMahameed, MD, MPH Division of Cardiology Beth Israel Deaconess Medical Center Boston

1. Differentiating Lower Extremity Pain: Arteries, Veins, and Nerves!The Value of the ABI Amjad AlMahameed, MD, MPH Division of Cardiology Beth Israel Deaconess Medical Center Boston

2. Objectives • Review the differential diagnosis of lower extremity dysfunction • Beyond intermittent claudication: Recognize the different clinical presentations of PAD • PAD as the cause of symptoms: Reflect on clinical evaluation

3. 68 Million Americans with CVD Stroke 4.4 million PAD 8.4 million HTN 50 million Heart 16.8 million AMI 7.2 mill Angina 6.3 mill CHF 4.6 mill PAD incidence expected to rise by 40% (M) and 15% (W) till 2030

4. D Dx of Leg Pain Neurogenic Causes - Lumbar canal stenosis - Peripheral neuropathy Musculoskeletal Causes: - Arthritis (lumbar disk, hip, knee) - Bursitis - Tendonitis - Tight hamstring/quadriceps Podiatric Causes: - Planter fasciitis - Tarsal Tunnel Syndrome Other Vascular: - Venous claudication - Takayasu’s, giant cell vasculitis - Thromboangiitis obliterans - Chronic Pernio

5. Are the Limb Symptoms Related to PAD?

6. Intermittent Claudication Predictable Leg pain induced by walking Classic triad of symptoms in patients with IC is seen in (11-33%) of all PAD pts Relief with resting (stopping/standing) Recurs when walking is resumed

7. Spectrum of Peripheral Arterial Disease Presentation Pain Soreness Ache Weakness Tiredness Numbness Tightness Discomfort Claudication Limb-Threatening Ischemia Poor wound healing Impending or overt gangrene Fatigue, heaviness Normal Mild Moderate Severe Rest pain Worsening Flow Limitation

8. Indications for the ABI • Non palpable pulses • Unexplained leg pain • Rest pain • Non healing sores or ulcers • Claudication • Risk stratification

9. Lower extremity systolic pressure ____________________________________________ Brachial artery systolic pressure ABI is 95% sensitive and 99% specific for PAD ABI =

10. R DP 130 mmHg R PT 110 mmHg ABI 0.72 R DP 180 mmHg R PT 180 mmHg ABI 1.0 180 mmHg 170 mmHg L transmit L Toe R transmit R Toe Higher R-Ankle SBP Right ABI 170 mmHg 180 mmHg Post Exercise Higher Arm SBP Higher R-Ankle SBP Left ABI Higher Arm SBP 130 mmHg 180 mmHg R Ankle L Ankle

11. Usefulness of the ABI • Diagnosis, localization, and monitoring PAD progression • Assess functional capacity (even asymptomatic pts) • Predictor of cardiovascular morbidity and mortality

12. 100 ABI >0.85 80 Patients Survival (%) 60 ABI 0.40–0.85 40 ABI <0.40 20 0 6 4 8 2 10 Year PAD Survival as a Factor of the ABI McKenna M, et al. Atherosclerosis. 1991;87:119-128.

13. PAD and Functional Impairment • Peripheral arterial disease (PAD) is associated with • Poorer walking endurance • Slower walking speed • Poorer balance • Compared to individuals without PAD Limited leisure and Work activities Olin JW. AM J Med 10-17,1998. Scherer SA. Arch phys Med Rehab 79:529-531,1998 Regensteiner JG. J Vasc Med Biol2:142-152,1990

14. Walking Performance in Asymptomatic Peripheral Arterial Disease McDermott M et al. JAMA 2004; 292:453-461.

15. Clinical Tips • The DP pulse is congenitally absent in up to 32% of normal individual but the absence of PT pulse is always abnormal • Lack of hair on the shins is not always a sign of PAD • Patients with rest pain may present with pitting edema • Persistence of pallor > 40 second after 1 minute elevation is indicative of severe disease

16. PAD is NOT the Cause of Leg Symptoms if: • History and physical exam not suggestive • Normal rest ABI and treadmill exercise testing • Presence of alternative diagnosis • In this process, you may also obtain spine MRI, X-rays of the hips and knees, and even EMG/NCS